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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202878
Report Date: 11/15/2022
Date Signed: 11/15/2022 10:46:40 AM

Document Has Been Signed on 11/15/2022 10:46 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:EASTLAKE VILLA HOME CAREFACILITY NUMBER:
445202878
ADMINISTRATOR:RECINTO, RACHELLEFACILITY TYPE:
740
ADDRESS:591 ARLENE DRIVETELEPHONE:
(213) 400-4341
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY: 10CENSUS: 0DATE:
11/15/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Rachelle RecintoTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) David Marrufo conducted a Prelicensing visit and met with Rachelle Recinto, Administrator and Dexlier Go.

During visit, LPA Marrufo toured the inside and outside of the facility. LPA Marrufo observed 2 out of 2 facility bathrooms had available soap and paper towels. The facility had a smoke and carbon monoxide detector that functioned properly when tested during visit. LPA Marrufo observed 6 out of 6 bedrooms and observed them to have available bedding, drawers, and functioning lights. The kitchen area had locked drawers for sharps and cleaning supplies. The office room had locked drawers for medications and records. The outdoor area exits were clear of obstructions.

During visit, LPA Marrufo reviewed the Component III presentation with Administrator.

No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed with Administrator Rachelle Recinto and Dexlier Go and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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